Two papers for your perusal this month, each looking at throwing all medicine has to offer at two diseases with potentially awful outcomes – cardiac arrest and ischaemic stroke.

In Berlin, when you have your stroke, there is a chance the ambulance will arrive carrying a neurologist, a CT scanner the size of a washing machine, a lab and a dose of tPA. You will get your thrombolysis faster, with each ambulance costing about a million Euros. In Melbourne, when you have your MI and the paramedics don’t get ROSC in 30 mins, the hospital team will not start making noises about stopping. Instead, you will be cooled, put on ECMO, and if required head straight off to the cath lab. If you survive (which you probably will) your brain will be about the same as it was before. I’m not going to write much about these studies, but instead post some questions and leave the rest to you. All replies are welcome, related to these questions or not:

What are the ethics of showing superb outcomes with a treatment that will not be universally available – do we do that anyway?

Should our treatments be directed towards diseases where outcomes are worst, where gains can be potentially greatest?

How would you decide when the costs of an intervention are not worth the gains?

Is it justifiable that the authors implemented a bundle of best practices, rather than each component being investigated in isolation (which may be cheaper)?

Is a ‘side effect’ of the use of ECMO in cardiac arrest that organs can be better preserved for transplant? – Is that a bad thing (ethically)?

Do you think these interventions could be implemented in the NE of England – if not why not? If so, how?

Bernard being the author of one of the two trials that led to cooling post cardiac arrest in the first place. They achieved a median temp drop from 35.5 - 33.8 (the 30ml/kg fluid was given in the ED) which is slightly more than Jae's calculation of the expected drop.

Agree 100% with the idea they will be cold and cooling for other reasons. Also, not my scope of experience but I would've thought once on ECMO you can make the temperature whatever you want it to be, did the cold fluid just add an unneccesary step for any possible benefit of being cold slightly earlier?